A Case of Resolved Vincristine-Induced Constipation Following Osteopathic Medicine in a Patient With Infantile Fibrosarcoma

Participants

• Number: 1

• Description: a baby girl, born at 40 weeks and 2 days to a 31-year-old mother, monitored from the first trimester of pregnancy. Both pregnancy and delivery went well, and vital signs, Apgar index, respiration and oral feeding were all normal. At birth, however, a facial mass was present on the right side of her face compatible with the diagnosis of infantile fibrosarcoma. Therefore, chemotherapy (vincristine, dactinomycin and cyclophosphamide) in 4-week cycles was started at 6 weeks of age.
  Throughout the first cycle, the child received lactulose for 24 hours after vincristine to regulate bowel activity. Seven days after the second cycle, the child was hospitalized for fever and abdominal distension, symptoms due to diffuse colonic pneumatosis. Treated with antibiotics and total parenteral nutrition, she was discharged 9 days later.
  She started taking lactulose for 48 hours after vincristine, but by the sixth cycle of chemotherapy, defecation became difficult without the use of lactulose: the stools were very hard and the use of lactulose was also needed several times during the week after chemotherapy.
  No other therapies (pharmacological and not) were used for constipation.
  At 7 months, the child received an osteopathic structural evaluation by two osteopathic physicians specializing in pediatrics, which revealed somatic dysfunction of the right condyle, of the diaphragm, the right paraspinal musculature adjacent to the thoracolumbar junction, of the abdominal wall in the left lower quadrant, of the inferior mesenteric ganglion, and of the sacroiliac joint. In addition, there were palpable residual stools in her colon.

Interventions and evaluations

• Evaluation of bowel movements and somatic dysfunctions
• 4 OMT sessions of 10 minutes.
• OMT:
  • myofascial release for the abdominal (mesentery and colon) and thoracic regions;
  • balanced ligamentous tensions for iliac dysfunction;
  • condylar decompression for the occiput dysfunction.
• Mesenteric release and colonic peristalsis stimulation techniques were taught to parents to be performed daily for 5 minutes, morning and evening.
• Chemotherapy and diet remained unchanged.

Results

After 1 week of OMT, the lactulose administered during the week decreased from 10 to 6 doses, and the child produced soft stools without any effort. After the second week, the lactulose decreased to 4 doses, and after the third week, the child was able to evacuate without any more use of lactulose.

During these weeks, the osteopathic examination found continuous improvement of the dysfunctions, and, most importantly, after the fourth week, no residual stool was perceptible in the colon. Some fascial restrictions remained at the abdominal level.

The child’s parents continued to perform the learned maneuvers at home, and there were no adverse effects.

Discussion

Chemotherapy-induced constipation may result from alterations in nerve endings at the level of the intestinal system, taking into account that constipation can be complicated by a variety of factors (eg, habits and medications). Consequently, all neurological, circulatory, and biomechanical causes that may influence bowel dysfunction should be considered.

For that reason, the practitioners, for example, treated the skull: the extrinsic innervation of the colon comes in fact from the vagus nerve, which emerges from the jugular foramen at the level of the atlanto-occipital joint. On the other hand, parasympathetic innervation of the distal colon and rectum comes from the preganglionic neurons of S2-4, while sympathetic innervation of the colon originates at the level of the thoracolumbar junction.

In addition, fascial restrictions of the mesentery and thoracic and pelvic diaphragms can play a central role in decreasing gastrointestinal motility, as well as altering the flow of oxygen, nutrients, and arterial blood. Therefore, it becomes essential to resolve these restrictions and promote lymphatic and venous drainage.

The use of non-pharmacological therapies for constipation is vital in populations with fragile conditions and at risk of infection or complications, such as pediatric oncology patients for instance. However, some classic expedients such as physical exercise, fiber consumption, increased water intake and discontinuation of drugs that can induce constipation are not always feasible. Consequently, a therapy such as OMT can become another important tool at our disposal, especially considering its simplicity, non-invasiveness, and good tolerance levels.

Obviously, this study is limited by the fact that it is a case report and the lack of a rationale to link the pathophysiology of chemotherapy-induced constipation to the efficacy of OMT. Moreover, this study is unlikely to be generalizable to patients taking drugs other than vincristine, which is known for its side effects on evacuation.

Future prospective studies are therefore needed to better examine the safety and feasibility of using OMT in pediatric oncology patients.